Accident / Incident Review

Presented to:

By:

Date:

Federal AviationAdministration

Orlando Flight Standards District Office

Accident / Incident Review

CFI Special Emphasis Program

Larry Enlow

May 28, 2014


2Accident / Incident Review

May 28, 2014

ORLANDO FSDOORLANDO FSDO

Flight Training

Accident & Incident

Analysis



May 28, 2014

ACCIDENT & INCIDENT ANALYSISACCIDENT & INCIDENT ANALYSISACCIDENT & INCIDENT ANALYSISACCIDENT & INCIDENT ANALYSIS The Orlando FSDO has carefully analyzed

422 flight training accidents & incidents occurring within the district since the beginning of FY 1999 to determine:

Causal FactorsTrends

Training DeficienciesAirworthiness Issues



May 28, 2014

ORLANDO FSDO ACCIDENT & INCIDENT SUMMARY

ORLANDO FSDO ACCIDENT & INCIDENT SUMMARY

FLIGHT TRAINING ACCIDENTS & INCIDENTS

1998 1999 2000 2001 2002 2003 2004

60 38 24 28 22 18 12

2005 2006 2007 2008 2009 2010 2011

18 25 30 44 24 32 33

2012 2013 2014

17 17 18*



May 28, 2014

FY 2007 ACCIDENT & INCIDENT DETAILED FY 2007 ACCIDENT & INCIDENT DETAILED SUMMARYSUMMARY


OCCURRENCE STUDENT & CFI SOLO STUDENT

COLLISION ON GND 1GO AROUND (single eng.) 1 HELO HOVER 3HELO SLOPE LND 1HELO AUTOROTATION 1 1WAKE TURBULENCE 1FUEL EXHAUSTION 1 GEAR-UP 3HARD LANDING (180 accu. lnd.) 1LANDING (loss of control) 2 14



May 28, 2014




COLLISION ON GND 1 3HELO HARD LANDING 1HELO AUTOROTATION 1HELO GROUND VIBRATION 1UNLATCHED CANOPY / DOOR 1 1SR-20 BRAKE FIRE 1LOSS OF POWER (water in fuel) 1TAKEOFF 3GEAR DOWN WATER LANDING 1GEAR-UP 6HARD LANDING 2LANDING (loss of control) 2 19



May 28, 2014




COLLISION ON GND 1 1HELO (dynamic rollover) 1HELO (hard landing) 1FUEL EXHAUSTION 1STALL / SPIN 1TAKEOFF (loss of control) 1GLIDER (off airport landing) 1GEAR-UP 6HARD LANDING 3LANDING (loss of control) 2 5



May 28, 2014




COLLISION ON GND 1HELO (hard landing) 3FUEL MISMANAGEMENT 1 1 TAKEOFF (loss of control) 1GEAR-UP 4LANDING (loss of control) 6 15



May 28, 2014




COLLISION ON GND 1STALL / SPIN 2FUEL EXHAUSTION 1HELICOPTER AUTOROTATION 1HELICOPTER GRASS FIRE 1GEAR-UP 4 LANDING (loss of control) 3 20



May 28, 2014




COLLISION ON GND 1 1HELICOPTER HARD LANDING 2HELICOPTER DYNAM. ROLL. 1ENGINE FIRE 1ABORTED TAKEOFF 2GEAR-UP 2 1HARD LANDING 2LANDING (loss of control) 4



May 28, 2014




COLLISION ON GROUND 4PA-28 ENGINE FIRE 1TAKEOFF (loss of control) 2GEAR-UP 1HARD LANDING 1* 4

* during practical testLANDING (loss of control) 1 3



May 28, 2014

FY 2014FY 2014** ACCIDENT & INCIDENT DETAILED ACCIDENT & INCIDENT DETAILED SUMMARYSUMMARY

FY 2014FY 2014** ACCIDENT & INCIDENT DETAILED ACCIDENT & INCIDENT DETAILED SUMMARYSUMMARY


COLLISION ON GROUND 1LOST DOOR IN FLIGHT 1GEAR-UP 2GEAR-DOWN WATER LANDING 1HARD LANDING 4 3HELO HARD LANDING 1LANDING (loss of control) 1 3 GLIDER LANDING (hit building) 1

* 05-27-2014



May 28, 2014

Orlando FSDO Flight Training Accidents & Orlando FSDO Flight Training Accidents & Incidents Involving Landings Incidents Involving Landings

Orlando FSDO Flight Training Accidents & Orlando FSDO Flight Training Accidents & Incidents Involving Landings Incidents Involving Landings

Student & CFI hard landings, gear-ups, & loss of control

Year Total Events Landing Events Ratio

2007 30 20 67 %

2008 44 30 68 %

2009 24 16 67 %

2010 32 25 78 %

2011 33 27 82 %

2012 17 9 52 %

2013 17 10 58 %

2014* 18 16 89 % 215 153 71 %



May 28, 2014

Opportunities for ImprovementOpportunities for ImprovementOpportunities for ImprovementOpportunities for Improvement

Significant improvement has been made as Pilot Schools, Check Instructors, and Pilot Examiners place special emphasis on landings

But 71 % of our district’s flight training accidents and incidents are still due to landing mishaps.

Maintain landing special emphasis initiative



May 28, 2014

PILOT SCHOOL RESPONSIBILITIESPILOT SCHOOL RESPONSIBILITIESPILOT SCHOOL RESPONSIBILITIESPILOT SCHOOL RESPONSIBILITIES

Pilot School Special Emphasis Initiatives

• Pre-solo stage checks by senior instructors • Additional supervised solo operations• Enhanced dual cross-country training• Supervised solo at cross-country destinations



May 28, 2014

FLIGHT INSTRUCTOR STUDENT SOLO FLIGHT INSTRUCTOR STUDENT SOLO RESPONSIBILIESRESPONSIBILIES


In order to solo, a student must be able to:

• Make competent go / no-go decisions for every flight• Determine the location of all other traffic while in the pattern• Establish and maintain a stabilized approach• Determine wind direction and make proper control inputs• Manage energy so landings occur at the touchdown point• Land with and maintain proper pitch attitude • Keep the longitudinal axis parallel to and over the centerline• Keep the centerline between the main wheels during landing• Correctly respond to any abnormality or emergency• Communicate properly & effectively with other traffic or ATC



May 28, 2014



If a student cannot perform the “solo checklist ”

functions without guidance or assistance from the flight instructor, then the student is not ready to solo



May 28, 2014

EVALUATOR RESPONSIBILITYEVALUATOR RESPONSIBILITYEVALUATOR RESPONSIBILITYEVALUATOR RESPONSIBILITY

If a student cannot perform the functions of the “Solo Checklist ” during a stage check, end-of- course test, or practical test, then the student’s performance is unsatisfactory

All 10 items on the “Solo Checklist” are supported by the applicable PTS and Airplane Flying Handbook



May 28, 2014

Opportunities for ImprovementOpportunities for ImprovementOpportunities for ImprovementOpportunities for Improvement

Special Emphasis Initiatives

• Place increased emphasis upon landings and gear operation during stage checks and end-of-course tests.

• Place significant emphasis upon proper instructional techniques and demonstration of landings and gear operations during flight instructor checks and tests.

• Develop scenario based questions applicable to landing gear system malfunctions.

• Test flight instructor “student error” intervention associated with landings and landing gear operations.

• Strictly apply PTS, “solo checklist”, and Airplane Flying Handbook guidelines.



May 28, 2014

Additional Evaluator ResponsibilityAdditional Evaluator ResponsibilityAdditional Evaluator ResponsibilityAdditional Evaluator Responsibility

Identify Training Deficiencies

Observe applicant’s seat position

Eye Level

Position of Feet on Rudders

Observe touchdown control movements

Proper Aileron Input for Crosswind

Elevator “Follow-through”

Automobile Driving “Negative Transfer”



May 28, 2014

Identify Training DeficienciesIdentify Training DeficienciesIdentify Training DeficienciesIdentify Training Deficiencies

“The eye can’t see what the mind does not know”

Upon completion of testing, Evaluators should de-brief all Students and their Flight Instructors

regarding Training Deficiencies

Evaluators must assure that accurate communication with the Student and Flight Instructor has been

accomplished



May 28, 2014

Additional Contributors to Orl FSDO Additional Contributors to Orl FSDO Flight Training Accidents & Incidents Flight Training Accidents & Incidents


Other Aircraft Flight Training & Testing

Gliders

Helicopters



May 28, 2014



Glider Events

2009 Off-airport landing with CFI aboard

2014 Student pilot hit building during landing



May 28, 2014



Helicopter Hard Landing, Hover, and Autorotation Events

Year Total Events Helo Events Ratio

2007 30 5 17 %

2008 44 3 7 %

2009 24 2 8 %

2010 32 3 9 %

2011 33 2 6 %

2012 17 3 18 %

2013 17 0 0 %

2014 18 1 5 %

215 19 8 %



May 28, 2014

Opportunities for ImprovementOpportunities for ImprovementOpportunities for ImprovementOpportunities for ImprovementHelicopter Special Emphasis Initiatives

• Place increased emphasis upon hover operations, landings and autorotations during all tests.

• Place significant emphasis upon proper instructional techniques and demonstration of hover operations, landings and autorotations during flight instructor tests.

• Develop scenario based questions applicable to helicopter system or component malfunctions.

• Test flight instructor “student error” intervention associated with hover operations, vertical takeoffs & landings (pick-ups & set-downs) and autorotations.



May 28, 2014

Pilot Deviation Special EmphasisPilot Deviation Special EmphasisPilot Deviation Special EmphasisPilot Deviation Special Emphasis

Special emphasis needed to reduce the number of pilot deviations occurring during flight training

• Use of airport diagrams for all surface operations• Modify method of conducting take-off briefing• Improve ATC listening skills with less talk in the cockpit• Emphasize situational and positional awareness during

all flight training operations

Presented to:

By:

Date:


Orlando Flight Standards District Office

Mechanically CausedAccident / Incident Review

141 / 142 Safety Summit

Larry Enlow

May 28, 2014



May 28, 2014

AIRWORTHINESS INITIATIVEAIRWORTHINESS INITIATIVEAIRWORTHINESS INITIATIVEAIRWORTHINESS INITIATIVE

The Orlando FSDO continues to place special emphasis on the airworthiness compliance of flight training aircraft.

Inspections

Analysis of Data



May 28, 2014

FY 2012 MECHANICALLY CAUSED ACCIDENT FY 2012 MECHANICALLY CAUSED ACCIDENT & INCIDENT DETAILED SUMMARY& INCIDENT DETAILED SUMMARY


OCCURRENCE CAUSE

1 SR-20 emer. landing on road Engine failure1 CE-172 emer. landing in field Engine failure1 HU-269 emer. autorotation into field Engine failure1 CE-172 smoke in cockpit Voltage reg. failure1 CE-172 RG right gear collapse Gear trunion failure1 BE-76 nose gear jammed Improper maint.1 PA-44 nose gear collapse Improper maint.1 PA-44 nose gear collapse Drag link bolt failure1 Light Sport nose gear collapse Gear component fail.1 CE-162 door opened in flight Latch design4 PA-28 engine fires while starting Carb. flooding 1 SR-20 brake failure Overheated brakes1 PA-28 propeller blade broke off Undetermined



May 28, 2014



OCCURRENCE CAUSE

1 UC-1 left brake failure Loss of brake fluid1 PA-34 smoke in cockpit Panel light control1 PA-28R loss of power Fuel inject. system1 PA-44 right main gear collapse Locking bracket

fail.1 CE-172RG left main gear collapse Gear strut pin

failure1 CE-172 emer. land. (oil on windshield) Engine case crack1 HU-269 emergency autorotation Engine failure 1 PA-34 rudder trim tab control rod failure Corrosion



May 28, 2014



OCCURRENCE CAUSE

1 SR-20 left brake failure Brake cylinder fail1 PA-44 left main gear collapse Trunnion attach.

fail.1 CE-182RG nose gear collapse Locking pin failure1 HU-269 emergency autorotation Undetermined1 Weight Shift lost power on takeoff Undetermined1 BE-76 nose gear collapse Gear door rod

bent1 PA-28R engine failure Loss of oil pressure2 PA-28 engine fires while starting Carb. flooding

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Accident / Incident Review

Education